What are the management options for ankylosing spondylitis?

Management of Ankylosing Spondylitis

Optimal management of ankylosing spondylitis requires combining NSAIDs as first-line pharmacological therapy with mandatory patient education and regular exercise, escalating to anti-TNF biologics for patients with persistently high disease activity despite adequate NSAID trials. 1, 2

Initial Assessment and Monitoring

Before initiating treatment, establish baseline disease activity using:

• Patient history with validated questionnaires (BASDAI score for disease activity) 1
• Clinical parameters: spinal mobility (modified Schober test, chest expansion, occiput-to-wall distance), peripheral joint involvement, enthesitis 1
• Laboratory markers: inflammatory markers (ESR) 1
• Imaging: AP and lateral lumbar spine x-rays, lateral cervical spine, AP pelvis (sacroiliac and hip joints) 1

Monitor disease progression every 2 years with radiographs in stable patients, though more frequent imaging may be warranted in rapidly progressing cases 1, 3

Non-Pharmacological Management (Mandatory for All Patients)

Patient education and regular exercise are cornerstone treatments that must be initiated immediately at diagnosis and continued throughout the disease course. 1, 2

• Supervised exercise programs are superior to home exercise alone and should be prioritized 2, 4
• Group physical therapy demonstrates better patient global assessment outcomes compared to individual therapy 3, 2
• Exercise programs improve function even when pain metrics show modest changes (Level II evidence) 4
• Specific multimodal programs combining Pilates, McKenzie, and Heckscher techniques show significant improvements in pain, spinal mobility (BASFI, BASDAI, BASMI), and pulmonary function when performed 3 times weekly 5

First-Line Pharmacological Treatment: NSAIDs

NSAIDs are the recommended first-line drug treatment for all patients with pain and stiffness, with Level Ib evidence demonstrating improvement in spinal pain, peripheral joint pain, and function over 6-week periods. 1, 3, 2

NSAID Selection Strategy:

• For patients with standard GI risk: Any NSAID at maximum tolerated dose 1
• For patients with increased GI risk: Either non-selective NSAID plus gastroprotective agent (PPI with RR 0.40 for serious GI events, or H2 blocker with RR 0.44) OR selective COX-2 inhibitor (RR 0.18 vs non-selective NSAIDs for serious GI events) 1
• Continuous NSAID treatment is preferred over on-demand use for patients with persistently active symptomatic disease 4

Critical Pitfall to Avoid:

Do not declare NSAID failure until the patient has tried at least two different NSAIDs at maximum tolerated doses for at least 3 months each. 2 Inadequate NSAID trials before escalating to biologics is a common error.

Second-Line Options for Inadequate NSAID Response

When NSAIDs are insufficient, contraindicated, or poorly tolerated:

• Analgesics (paracetamol, opioids) for residual pain control 1, 2
• Local corticosteroid injections for peripheral arthritis, enthesitis, or specific sites of musculoskeletal inflammation 1, 2, 4
• Avoid systemic corticosteroids for axial disease—no evidence supports their use and they carry significant side effects 1, 2, 4

DMARDs for Peripheral Disease Only:

• Sulfasalazine may be considered for patients with peripheral arthritis (not axial disease) 1, 6
• No evidence supports methotrexate or other conventional DMARDs for axial disease 1, 6

Biologic Therapy for Refractory Disease

Anti-TNF treatment should be initiated in patients with persistently high disease activity (BASDAI >4) despite at least two NSAIDs at maximum dose for at least 3 months total. 1, 2, 7

FDA-Approved Anti-TNF Agents:

Adalimumab (Humira):

• Dosing: 40 mg subcutaneously every other week 6
• Can be used alone—no obligatory requirement for concomitant DMARDs in axial disease 1, 7
• Level Ib evidence supports large treatment effects for spinal pain and function over at least 6 months 1

Etanercept (Enbrel):

• Dosing: 50 mg subcutaneously weekly 7
• Level Ib evidence for efficacy in reducing signs and symptoms 1, 7

Critical Safety Monitoring for Anti-TNF Therapy:

• Test for latent tuberculosis before initiating and periodically during therapy—treat latent TB before starting biologics 6, 7
• Monitor closely for serious infections (bacterial, viral, fungal including histoplasmosis) that may present with disseminated disease 6, 7
• Discontinue immediately if serious infection or sepsis develops 7
• Be aware of increased lymphoma risk, particularly hepatosplenic T-cell lymphoma in young males receiving concomitant azathioprine or 6-mercaptopurine 6, 7

Emerging Biologics:

• IL-17 inhibitors (secukinumab) and JAK inhibitors show efficacy and good tolerability, including in HLA-B27 negative patients 4, 8

Surgical Management

Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural hip damage, independent of age. 1, 9

• Spinal corrective osteotomy and stabilization procedures may benefit selected patients with severe spinal deformities 1, 9

Common Pitfalls to Avoid

• Overreliance on imaging without clinical correlation leads to unnecessary interventions 3, 2
• Failure to incorporate both pharmacological and non-pharmacological approaches significantly limits treatment effectiveness 3, 2
• Premature escalation to biologics without adequate NSAID trials (minimum two different NSAIDs for 3 months each at maximum dose) 2
• Using systemic corticosteroids for axial disease—no evidence supports this and side effects are substantial 1, 2, 4
• Requiring DMARDs before anti-TNF therapy in axial disease—this is not evidence-based and delays effective treatment 1, 7